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Transcript of Postpartum Hemorrhage
It causes profound bleeding because vascular beds in the genital tract are engorged during pregnancy.
- Vaginal or cervical laceration
Mostly due to instrumental delivery, Precipitous labor, Large baby.
- Uterine rupture.
Could be perineal, vaginal or broad ligament.
- Uterine inversion.
Sometimes counted as a separate cause. Trauma Occasionally, parts of the placenta or membranes can be retained and this can be identified by careful examination of the placenta following delivery.
A retained placenta (‘tissue’) can also prevent a uterus from contracting efficiently until the tissue is removed.
incomplete separation of the placenta accreta or precreta can cause also 2ndry PPH. Tissue Primary postpartum haemorrhage (PPH) is the most common form of major obstetric haemorrhage.
The traditional definition of primary PPH is the loss of 500 ml or more of blood from the genital tract within 24 hours of the birth of a baby.
PPH can be minor (500–1000 ml) or major (more than 1000 ml).
Major could be divided to moderate (1000–2000 ml) or severe (more than 2000 ml).
The recommendations in this guideline apply to women experiencing primary PPH of 500 ml or more. Primary PPH Risk Factors for Primary PPH Postpartum hemorrhage (PPH) is the leading cause of maternal mortality
All women who carry a pregnancy beyond 20 weeks’ gestation are at risk for PPH and its sequelae.
In the developing countries, maternal mortality due to PPH may reach 25% of all maternal deaths.
Bleeding is normal after any delivery.
The average amount of blood loss after the birth of a single baby in vaginal delivery is about 150-300 ml .
And in cesarean birth is approximately 800-1,000 ml .
This loss is well tolerated because there are 30%-50% increase in plasma volume and a 24% increase in RBC’s volume by the 3rd trimester. PPH is defined as blood loss of more than 500 mL following vaginal delivery or more than 1000 mL following cesarean delivery.
The problem with this definition is that it is objective, and because of that many other definitions were established.
10% drop in PCV can be used sometimes to define PPH but the problem with this definitions is:- Not accurate- Can be retrospective if done late
Another definition is any blood loss that will lead to signs and symptoms of hydrostatic instability.
We cannot relay on this definition because the blood loss will be different from one patient to another, like patients with anemia, cardiovascular diseases, PET or dehydration have decreased capacity to cope with the blood loss. Definition of PPH It is divided according to the timing of the bleeding to:
- Primary: in the first 24hrs, especially in first 6 hours.
- Secondary: from the second day till 12th week post partum, especially in the second week after delivery. Definition of PPH At term, the estimated blood flow to the uterus is 500-800 mL/min, which constitutes 10-15% of cardiac output.
Most of this flow traverses the low-resistance placental bed.
The natural haemostatic mechanisms that minimize bleeding are :
- Contraction & Retraction of the myometrial fibers.
Retraction is the unique characteristic of the uterine muscle to maintain its shortened length following each successive contraction.
This arrangement of muscle bundles has been referred to as the "living ligatures" or "physiologic sutures" of the uterus.
- Hypercoagulable state in late pregnancy.
- Integrity of the genital tract. Physiology of PPH PPH like any other obstetric emergencies can often be predicted, 1/3 of the cases have predisposing risk factors.
Preventative measures should be undertaken if significant risk factors are present.
The risk factors are divided into Pre-existing (maternal and fetal) and Intrapartum Pre-existing Risk Factors They are divided into maternal and fetal risk factors;
Maternal risk factors:
- Advanced maternal age
- Grand multiparity
- Uterine fibroids
- Previous C/S
- Bleeding disorders
- APH (abruptio)
- Previous PPH
- Hypertension Fetal risk factors:
- Large baby
- multiple pregnancy
- shoulder dystocia
- polyhydramnios The Risk factors are:
- Prolonged labor (mainly third stage)
- Caesarean section
- Instrumental delivery
- Pyrexia in labor
- Episiotomy (mainly in Left Mediolateral)
- Induced/Augmented labor Intrapartum Risk Factors The bleeding is mostly from endometrial spiral arterioles and decidual vein that previously supplied and drain the intervillous spaces of the placenta, normally when the placenta separates during labor bleeding occur. Etiology of PPH The etiology of PPH can be remembered as 4Ts:
- Tone (70%)
- Trauma (20%) including the Uterine inversion
- Tissue (10%)
- Thrombin (1%) Uterine atony, or failure of the uterus to contract and retract after the delivery of the placenta.
It is the most common cause of PPH (70%).
Can sometimes lead to torrential loss of blood immediately following delivery. Tone Uterine atony can be predicted, and therefore steps can be taken to prevent it.
1. Overdistention of the uterus can be caused by:
a) Multiple gestation
b) Fetal macrosomia
In these cases the uterus is large so after delivery it will not contract properly leading to PPH.
2. Prolong labor: will cause fatigue to the uterine muscle which lead to poor contraction .
3. Drugs: Inhibition of contraction by drugs (halogenated anesthetic agents, nitrate, NSAD, magnesium sulfate and nifedipine)
4. Placenta previa cause decrease in the relative content of musculature of the wall
5. Bacterial toxin (chorioamnionitis , endometritis and septicemia ).
6. Uterine fibroid (esp. intramural)
7. Grand multiparity >5
8. Precipitous labor
It is rapid delivery lasting <3 hours, it causes violent contractions & rapid dilatations leading to atonia
9.Abruptio placentaespecially In the concealed type due to interstitial bleeding (infiltration of blood into the uterine muscles). Predisposing Factors for Uterine Atony After completing the first two steps of management of PPH we have to manage the cause of the PPH.
Initial step = bimanual uterine massage and compression.
And this is done to stimulate the uterine contraction and express any clots.
The second step is usage of drugs.
Medications: Insufficient evidence that one is superior
- Oxytocin (DOC)
- no contraindication.
- Hypotension with IV push.
- Contraindicated in hypertension/PIH.
- Side effects: HTN, nausea, palpitations, HA
- Placental entrapment (rare)
-Side effects: nausea, diarrhea, flushing, headache.
- Caution: asthma, HTN, cardio-pulmonary disease.
- Misoprostol (rectal) Management of Atony Management of Trauma Cervical lacerations:
- Visualize the cervix with a ring forceps.
- Small ( < 2cm) non-bleeding laceration don’t need suturing.
- Use an absorbable , interlocking stitch.
- Observe for bleeding after approximating the edge.
- Apply Pressure or packing over the repair.
- An absorbable , continues , interlocking stitch is used.
- Approximate the two ends together without leaving a dead space. Management of Trauma - Laceration If large & Expanding :
- incision & drainage.
- ligation of bleeding arteries.
- Packing for 24-36 hrs.
If small and stable :
Expectant management. Management of Trauma - Hematoma Reduction of uterine inversion (Johnson method).
Done through three steps. Management of Uterine Inversion Associated with uterine surgery
A low transverse or unknown uterine scar, Subtotal or Total abdominal Hysterectomy
- Sudden change in FHR tracing
- Vaginal bleeding
- Abdominal tenderness
- Maternal tachycardia
- Signs of shock are out of proportion to visible blood loss. Uterine Rupture Rare 1/20000 pregnancies, but important to recognize quickly.
Happens after the second stage of labor directly due to uterine atony, open cervix, attached placenta and most likely inexperienced physician trying to pull the placenta.
Suspect if shock disproportionate to blood loss.
Replace uterus immediately.
Watch for vasovagal reflex.
Inversion will lead to traction of peritoneal structures and this can elicit vasovagal attack which in turn will lead to vasodilatation and hypovolemic shock. Uterine Inversion Mostly will require surgical intervention .
The First Suture must be placed well above the apex of laceration , and that is to incorporate any bleeding arterioles into the ligation .
Requires appropriate analgesia, good lighting and position. Brandt Maneuver The Brandt-Andrews Maneuver is a manual technique to help facilitate the delivery of the placenta. Abnormal Uteroplacental Implantation The most important step is that the tissue must be removed even if bleeding stopped with the use of uretrotonics or manually.
- Reduces rate of manual removal and other consequences of retained placenta.
- 2 ml (20 IU) diluted into 20 ml NS.-Injected into placental side of clamped cord. Management of Tissue The rarest cause of PPH.
It can contribute to an excessive blood loss in a well contracted uterus.
Pre-existing conditions- ITP, von Willebrands
- Hypertensive disorders
- Unidentified Fetal demise
- Sepsis leading to DIC
- Amniotic fluid embolus
Drugs (e.g. aspirin) Thrombin Treatment guidelines:
-Treat underlying disorder
- Fibrinogen > 100mg/dl with FFP
- Platelets > 50,000 with packed platelets
- Hematocrit > 30% with PRBC
- Fresh frozen plasma:
supplies all factors except platelets. ( 1 U = 1g fibrinogen) .
- Cryoprecipitate : factor VIII, XIII & fibrinogen are 3-10 X conc. Than in FFP.
- Platelet concentrate :in case of thrombocytopenia, 1U increase plat. count 20,000-25,000.
- Packed RBCs : 1U raises Hb by 1 g/dl. Management of Thrombin Etiology:
RPOC (Retained Products of Conception) - the commonest.
Infection (2° to RPOC).
Others (rare): Blood disorders, Hormonal contraception, Carcinoma of the cervix, Uterine Artery Pseudoaneurysm with AV Malformation. Secondary PPH A 25 year old Papua New Guinean multiparous woman has just arrived at the hospital at 3 AM and precipitously delivered a viable term male infant. There were no obvious obstetrical lacerations. After 30 minutes, the midwife delivers the placenta, but this is followed by active hemorrhage. An IV was started about 20 minutes after delivery because the placenta had not delivered. The midwife was concerned for a possible retained placenta. Ten units of oxytocin is administered IM and 20 units of oxytocin was added to the liter of Hartman’s solutions. Brisk hemorrhage is still present. The midwife calls you at 3:30 AM and wakes you up from a deep sleep. Your living quarters are 150 yards from the hospital, and it is pouring rain outside. She informs you that there is a patient in the labor room with retained products of conception. How would you best respond to this situation? case presentation How to approach ?? The clinical history should be taken as a primary survey (ABCs) of the patient.
Keep in mind, that if the bleeding is very brisk, the patient’s mental status may wane.
this first set of questions should include queries about :
Signs and symptoms.
Identifying the cause of postpartum hemorrhage (PPH),
and selecting appropriate therapies History Severity of bleeding
- Is the placenta delivered? And duration of the third stage of labor?
- Was initial post delivery bleeding light, medium, or heavy? And How long has the bleeding been heavy?
- Symptoms of hypovolemia … ?
- If evaluating a patient with delayed postpartum hemorrhage, what has been the bleeding pattern since delivery?
- Then ask about blood transfusion history ? Reasons ? Any reactions?
Predisposing factors and potential etiology
- Previous PPH
- Gravity, parity, length of most recent pregnancy, history of multiple gestations
- Number of fetuses for the most recent pregnancy
- Pregnancy complications (polyhydramnios, infection, vaginal bleeding, placental abnormalities)
- If the placental was delivered, was it spontaneous, or was manual delivery required?
- Current and past history of vaginal delivery versus cesarean delivery
-Other uterine surgeries such as myomectomy (transvaginal vs transabdominal), uterine septum removal
- Personal or family history of bleeding disorder
- Medications history (with particular attention to anticoagulants, platelet inhibitors, uterine relaxants, and antihypertensives).
- Vaginal penetration since delivery (tampons, finger, other foreign object, vaginal intercourse)
- Signs or symptoms of infection such as uterine pain or tenderness, fever, tachycardia, or foul vaginal discharge.
- Ask about the delivery , when & where ? And who assisted the delivery ?
- Where and with whom was prenatal care?
- Healthy infant delivered , Any complications ?
- Past medical & surgical history. Assess vital organs including:
Pulmonary system (evidence of pulmonary edema).
cardiovascular (heart murmur, tachycardia, strength of peripheral pulses).
Neurological systems (mental status changes due to hypovolemia).
Skin should also be checked for petechiae or oozing from skin puncture sites indicating coagulopathy.
Abdominal examination: Pain and tenderness (concerning for retained placenta tissue, rupture, or endometritis), distension, palpable uterus (at or above the umbilicus) is suggestive of atony.
- Palpation of an overdistended bladder may indicate a barrier to adequate uterine contraction.
Perineal examination: identify any perineal lacerations or visible bleed.
Speculum examination: Careful inspection of the cervix and vagina under good light may reveal the presence and extent of lacerations.
Bimanual examination: bimanual palpation of the uterus may reveal bogginess, atony, uterine enlargement or any accumulated blood. Palpation may also reveal hematomas in the vagina or pelvis. Also to Assess if the cervical os is open or closed.
Placental examination: Examine the placenta for any retained placental tissue. Physical exam Complete blood count (CBC):
- hemoglobin and hematocrit
- If the white blood cell count is elevated, suspect endometritis or toxic shock syndrome.
- Look for thrombocytopenia.
Coagulation laboratory studies: (PT), (aPTT) , (INR) & Fibrinogen level for coagulopathy.
Electrolytes: Check for hypocalcemia, hypokalemia, and hypomagnesemia to set as a baseline for comparison during and after fluid and/or blood resuscitation.
Others: KFT ,LFT, amylase, lipase … Laboratory Studies Ultrasonography
MRI Imaging Studies Ultrasonography is a fast and helpful modality for imaging pelvic structures and should be the first-line study for pelvic pathology.
In general, a dedicated pelvic ultrasonography (transabdominal and/or transvaginal) is helpful in identifying large retained placental fragments, hematomas, or other intrauterine abnormalities.
Using a Doppler ultrasound to look for vascularity can help to differential between the clots being avascular and retained placenta often receiving persistent blood flow from the uterus.
U/S cannot reliably differentiate between blood, urine, or ascites; however, in the setting of suspected hemorrhage, any fluid in the abdomen should prompt further investigation. Ultrasonography can detail pelvic hematomas, cesarean delivery wound dehiscence and retained placental tissue. Computed tomography rarely performed from the ED in these patients.
helpful to determine if a fluid collection (hematoma or abscess) is intrauterine or extrauterine .
help to distinguish a placenta accreta from simple retained products of conception. Magnetic resonance imaging Routs Of Management
Evaluation of the response
Management of the underlying cause
Surgical Intervention Emergency Department Care PPH is one of the few obstetric complications with an effective preventive intervention.
Active management of the third stage of labor is considered the single most effective way to prevent PPH.
Management of the third stage of labor should therefore includes:
- Administration of a prophylactic uterotonic (usually
Oxytocin 10units IM )
- Controlled cord traction.
- Early cord clamping and cutting.
- Fundal massage after delivery of the placenta. prevention Other preventive measures may either increase the woman’s chance of survival or prevent conditions associated with causes of PPH including:
1- During antenatal care:
Detect and treat anemia.
Prepare well for delivery (skilled birth attendants )
2- During labor:
Provide active management of the third stage of labor
do not massage the uterus prior to delivery of the placenta
encourage the woman to keep her bladder empty
assist the woman in the delivery of the baby’s head and shoulders to help in preventing tears.
3- After delivery of the placenta:
Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations.
The placenta should be inspected for completeness.
monitor uterine hardness and any vaginal bleeding every 15 minutes for at least the first two hours, and massage the uterus at regular intervals after placental delivery to keep the uterus well-contracted and firm.
Breastfeeding as soon as possible. Although a loss of more than 500 ml is arbitrarily defined as a postpartum hemorrhage, any loss which appears excessive must be treated at once. Even a small loss may be dangerous in an anemic patient
the correct management of the third stage of labor is the most important factor in avoiding postpartum hemorrhage
Unpredictable -be prepared!
Uterine atony is the main cause.
Remember 4-Ts:–Tone, Trauma, Tissue, Thrombin.
Consider active management of third stage. "take home" notes under supervision of
Dr. Jehan Hamadneh By ...
Murtada Bograin C.S.
Severe meconium staining in liquor.
Long labor with multiple examinations.
Manual removal of placenta.
Mother’s age at extremes of reproductive span.
Low socio-economic status.
Internal fetal monitoring Risk factors Crampy abdominal pain.
Uterus larger than appropriate.
Passage of bits of placental tissue.
Signs of infections. Associated symptoms oxygen initially by mask
foley catheter into the bladder and fluid balance chart
cross match blood at least 6 units
prepare FFP, platelets and cryoprecipitate" as a summary 1- lapratomy to remove any free blood and inspect for any injury & repair it.
2- uterine artery ligation
3- internal iliac (inferior hypogastric) artery ligation (reduce bleeding from all sources within the geintal tract)
4- Total hysterectomy (curative treatment)
5- selective artirial embolyzation surgical intervention -Administer oxygen by mask.
-Place 2 large-bore (14-gauge) intravenous lines, establish a central venous line if necessary.
-Draw blood; CBC count, coagulation screen, urea level, creatinine value, and electrolyte status. (this is important to establish a baseline).
-Begin immediate rapid fluid replacement with NS or Ringer lactate solution.
(the loss of 1L of blood requires replacement 4-5L of crystalloid)
- Transfuse with PRBCs as available and appropriate
- Give FFP if coagulation test results are abnormal and sites are oozing.
- Give cryoprecipitate if abnormal coagulation test results are not corrected with FFP and bleeding continues.
- Give platelet concentrates if the platelet count is less than 50 X 10/L and bleeding continues. Resusitation Monitor the Pulse , Blood Pressure , Urine output , Blood gases and the level of consciousness .
Order regular CBC counts and coagulation tests to guide blood component therapy . Evaluation of the response